Development of a nutritionally adequate and culturally appropriate weaning food in Kwara State, Nigeria: An interdisciplinary approach

Sot. Sci. Med. Vol. 33. No. IO, pp. 1103-I 1 I I, 1991 0277-9536/91 $3.00 + 0.00 Printed in Great Britain Pcrgamon Press plc

DEVELOPMENT OF A NUTRITIONALLY ADEQUATE AND CULTURALLY APPROPRIATE WEANING FOOD IN

KWARA STATE, NIGERIA: AN INTERDISCIPLINARY APPROACH

MARGARET E. BENTLEY,’ KATHERINE L. DICKIN,’ SABA MEBRAHTU,~ BODE KAYODE,’ GBOLAHAN A. ONI,) CECELIA C. VERZOSA,” KENNETH H. BROWN’ and JOSEPH R. IDOWU’

‘Department of International Health, School of Hygiene and Public Health, The Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, U.S.A., *Cornell University, Department of Nutritional Sciences, Ithaca, NY 14853, U.S.A., ‘Department of Community Health and Epidemiology, University of Ilorin, Ilorin, Nigeria, 4The Academy for Educational Development, Washington, D.C.,

U.S.A. and ‘Department of Public Health, Ministry of Health, Ilorin, Nigeria

Abstract-A nutrition education program was undertaken in Kwara State, Nigeria to improve infant feeding practices and nutritional status of weaning-aged children. A series of ethnographic, market survey, epidemiological, dietary, clinical, and communications research studies were implemented to develop a culturally acceptable, yet nutritionally adequate, weaning food. A premise of the project was that the development and introduction of any new weaning food should be based upon ingredients available in the community and to households, at a low cost and with minimum preparation time, and that would be culturally acceptable by mothers for feeding young children.

Initially, research was conducted to define the problem in both nutritional and anthropological terms. Data was collected to describe: (I) present patterns of infant feeding and their determinants; and (2) dietary intake and nutritional status of infants in the intervention area. This paper focuses on the process of defining the problem and developing an intervention from an interdisciplinary perspective. The development of the new weaning food, Eko-Ilera, a fortified pap based on the traditional weaning food, is described.

Key words-Nigeria, infant feeding patterns, nutrition intervention, social marketing

INTRODUmION

This paper reports on a weaning intervention implemented in Kwara State, Nigeria, as part of the Dietary Management of Diarrhea (DMD) Program. The project was a collaborative effort of the Univer- sity of Ilorin, the University of Lagos, the Nigerian Federal Ministry of Health, the Kwara State Ministry of Health, the Academy for Educational Develop- ment, and the Johns Hopkins University. The DMD project was also implemented in Peru, where program activities ran about six months ahead of activities in Nigeria. A number of publications describe the results of both project sites [l-8].

A series of ethnographic, epidemiological, dietary, and clinical studies were implemented to develop a culturally acceptable intervention to improve weaning practices and infant nutrition among infants and young children. This type of public health program provides the opportunity to examine the factors that may influence the acceptance of a nutrition intervention at the community and household level. The paper argues that an interdisciplinary approach and community participation is required to develop new weaning recipes that are culturally appropriate, acceptable, and sustainable.

The project launched a pilot intervention in communities surrounding twelve health centers in Kwara State. An evaluation of the pilot intervention has been completed and provides detailed qualitative and

quantitative information on acceptability and dietary impact [8].

This paper briefly describes present patterns of infant feeding, dietary intake, and nutritional status of infants in the intervention area. Emphasis is placed upon: (1) the nutritional and sociocultural factors that were evaluated in order to design a feasible intervention program; and (2) the behavioral changes required for adoption of the recipe by the target population.

The setting

The project is based in the Yoruba-speaking area of Kwara State, which is located in the upland savanna of southwestern Nigeria. At the time of the study, the population of Kwara State was estimated at about 3 million people, of which about 80% are Yoruba. There are 12 “Local Government Areas” (LGA’s) in Kwara State and the Yoruba are found predominantly in seven of the twelve.

In the household survey, 2655 mothers were interviewed. Of these, 63.7% were Muslim while the rest were Christians. However, the 5 non-Yoruba speaking LGA’s are inhabited predominantly by Muslims.

Women in this area have a heavy work burden, with the majority working outside of the home for several hours/day. Of the 2655 mothers interviewed, 4.1% were engaged in agriculture while the majority (74.4%) were involved in marketing and petty

1103

1104 MARGARET E. BENTLEY er al.

Table 1. Number (%) of children breastfeeding by age group and residence

Age group (months)

O-5 6-11

12-17 18-23 24-35

Urban Rural

NO. NO. NO. No. children breastfeeding % children breastfeeding %

255 252 98.8 363 359 98.9 210 216 98.6 349 346 99.1 196 153 78.1 278 225 80.9 116 28 24.1 204 96 47. I 172 5 2.9 281 29 10.3

trading, following traditional patterns of gender- related work roles [9]. Although recent work in Nigeria has shown that women are increasingly play- ing a more active role in agriculture [IO-121, based on our survey data women in this area are still primarily traders. Our ethnographic data, however, suggest that women are feeling pressures to become more involved in agricultural work to provide food and cash to their households [13]. Reasons reported included the decline in labor availability due to male emigration to urban centers, decreased access to ‘good’ land, and the inability of household income to provide food needs because of inflation and increasing prices.

Among traders, 75% reported that they do their trading away from their homes. The average number of hours spent in a non-domestic work/day is 6.9 hr (SD = 3.2 hr). About 80% of the women reported that their children accompanied them during their market work, while 11% are cared for by grand- parents. The remainder leave their children with an older female sibling, another relative, or a neighbor. These child care patterns have implications for child feeding and the ability of the mothers to prepare and feed special foods. Our ethnographic data, however, suggest that Yoruba women perceived petty trading to be highly compatible with their responsi- bilities in domestic sphere. The majority of women

reported that they preferred trading to farming and only a few felt they were either overworked or too busy [13].

Present patterns of infant feeding in Kwara State, Nigeria

Based on ethnographic, survey, and dietary studies undertaken by the DMD project, several trends of infant feeding patterns have been documented in the intervention area [l-4,8, 141. Breastfeeding is in- itiated by nearly all women in both urban and rural areas, and continues through the second year of life for about half of rural and one-quarter of urban women (Table 1). Forty-two percent of children six months and younger are supplemented with a liquid pap (eko), prepared from fermented sorghum or maize paste (ogi), while 44% of this age group receive some amount of infant formula [4].

Foods commonly consumed by both urban and rural infants are shown in Table 2. The table shows that the most commonly consumed food is pap (eko), consumed at least once a week by nearly 100% of infants by the time they are one year of age. Foods that are of less importance in the early weaning period include cowpea, rice, yam flour, cassava, and groundnuts, but these are not consumed by the majority of children until after the child is one year of age.

Table 2. Percentage of children consuming specific foods at least once weekly by age group and residence

Age group (months)

o-5 6-11 12-17 la-23 24-35 Food Residence (n = 666) (n = 594) (n = 510) (n = 365) (n = 513)

Eko mimu (liquid pap) Urban 40 95 94 91 88 Rural 46 96 90 85 84

Eko jije (solid pap) Urban 3 23 48 60 73 Rural 3 14 46 65 70

Rice Urban 5 45 84 90 97 Rural 3 29 66 82 95

Amala (cassava or yam) Urban 4 33 67 86 96 Rural 3 29 66 82 95

Bread Urban 3 29 36 77 91 Rural 2 21 41 81 80

Ewa (Lxans/cowpeas) Urban 9 63 85 91 97 Rural 5 46 77 90 93

Epa (groundnut) Urban 2 18 49 69 78 Rural 2

:; 59 65 74

Egusi (melon seed soup) Urban 5 69 81 91 Rural 5 23 56 76 82

Eggs Urban 9 53 7s 86 88 RWZil 7 45 70 16 75

Condensed/other milk Urban 5 24 43 56 Rural 22 46 46 :; Infant formula Urban 5: 23 10 9 8

Rural 51 10 4 4 2 Oil Urban 8 55 8S 91 97

Rural 2 5 27 54 74 Sugar Urban 16 45 63 74 87

Rural 15 43 59 7s 78

Weaning food in Kwdra State, Nigeria

Since the liquid pap (eko) is the most important dietary item of weaning-aged children, some discussion of its preparation is necessary [2]. Either maize or sorghum (guinea corn) cereal grains are soaked in water for l-3 days, allowing fermentation. The product is then wet-milled and sieved to separate the ‘chaff’ from the cereal paste (ogi). The ogi paste is then stored under fresh water (for a maximum of 3-4 days) until it is diluted in boiling water and cooked for use as a weaning pap (eke), or as a thicker porridge, consumed by other household members. The ogi preparation process is done both within the household and by ‘professional’ village ogi makers, the product of which is available for sale in all villages.

Ethnographic studies investigated mothers’ perceptions about the appropriate age to introduce solid foods [I, 141. In rural areas, mothers felt that infants should receive only breast milk and pap until they were close to one year of age, although survey data showed that about half of children do receive some amount of other foods between 6-12 months. The foods that are offered to this age group are those that mothers consider to be ‘light’. However, the contri- bution of non-breastmilk foods to energy intake is small, representing only 23% of total energy intake in the under 12 age group [2-31.

Mothers were concerned that an earlier introduction of solid foods, particularly ‘heavy’ solids such as pounded yam (eba iyon) could result in the child becoming ‘heavy’ (~iwo), which is considered an unhealthy state [9]. A heavy child is ‘heavy to pick up’, ‘sick’, ‘irritable’, and ‘not active’. In addition, some mothers described the classic symptoms of kwashiorkor (colored hair, edemous skin) as a vari- ation of wiwo. A healthy child is one who is considered ‘light’ (jiicye), defined as ‘active, not sick, and light to pick up’. The concept of growth and development was not mentioned by mothers as a character- istic of child health. Although feeding specific foods can lead to ill or good health, the concept of food providing nutrition for growth is generally absent. In addition to these folk classifications of child health, many mothers felt that the child simply could not swallow foods of a solid or semi-solid consistency. Some mothers reported that a child who received ‘adult’ foods such as pounded yam and cassava ‘too early’ would not be able to develop or walk correctly, and that this could also result in the onset of illness, including diarrhea. These cultural concerns about the appropriate type and consistency of food explain, at least in part, the predominance of eko as an infant food among children less than one year of age. This is because ogi, when prepared as a liquid pap (eko) is an extremely dilute mixture when first prepared, and it may be further diluted at the time of serving. The energy content of a prepared serving of maize pap is 25.4 kcal/lOOg (SD 15.6 kcal/lOOg) and of sorghum pap is 26.9 kcal/lOO g (SD 17.8 kcal/lOO g) [2-31.

Fig. I. Handfeeding of traditional pap, eko.

mother’s leg while she is seated. The mother then places her cupped hand over the child’s mouth to serve as a funnel for a liquid or semi-liquid food. When the child is unwilling to eat, the mother can force liquids into the child’s mouth by simultaneously occluding the nose with her cupped hand. The child is then unable to breathe until swallowing all of the food [2].

Although this traditional practice is actively dis- couraged by the pediatric and public health community because of its hypothesized risk for aspiration pneumonia and otitis media (Fagbule and Grange, personal communication), it is indeed a commonly practiced mode of feeding in both urban and rural areas, with nearly 80% of both urban and rural mothers reporting this practice [4] (Table 3). Ethno- graphic research showed that mothers favor ‘handfeeding’ because it ‘saves time’. Mothers also reported that they ‘force-fed’ more when their children resisted hand-feeding. A structured observation datasheet was developed that coded whether mothers hand-fed, force-fed, or spoon-fed the pap for each feeding episode during repeated 12-hr observation days. As

Table 3. Percentage of mothers reporting current handfeeding by age group and residence*

The most commonly practiced mode of feeding eko to infants is to ‘hand-feed’ the liquid pap (Fig. l), which is described as follows:

Age group (months)

l&5 6-I I

12-17

Residence Total

n Urban n Rural n

99 70.7 278 69.3 377 IO2 88.2 300 86.0 402 80 77.5 236 69.5 316

18-23 40 45.0 177 52.0 217 2635 54 20.4 219 20. I 273

During hand-feeding the child is usually held either supine across the mother’s lap or with the head suspended from the

*Mothers who did not know or refused to answer the question were not included in this analysis.

1106 MARGARET E. BENTLEY et al.

Table 4. Mean number of minutes in a pap feeding broken down by mode of feeding

Minutes

Mode of feeding

Hand Force

X ” STD

2.60 267 2.05 2.72 284 1.34

Spoon 6.05 93 3.26

shown in Table 4, mothers are able to complete a feeding episode in less than three minutes if they hand- or force-feed, while feeding time more than doubled when children are spoon-fed (P < 0.0001 for all differences). Thus, the amount of time it takes to feed a child may be an important factor in motivating mothers to change infant feeding patterns in this area. Indeed, ethnographic data supported this hypothesis.

In addition to this time factor, mothers reported that they ‘have always fed this way’. Interviews with grandmothers confirmed that this is indeed a traditional feeding pattern, one that has been passed down for generations. Several of the mothers and grandmothers reported that handfeeding is an ‘art’ that must be learned, and that if done wrong, children can choke on the liquid.

An analysis of the DMD survey data (n = 2431 mothers) focused on the determinants of hand and force-feeding [4]. There were no apparent differences among urban and rural mothers in the prevalence of hand/force feeding, nor were there socioeconomic, demographic, or religious factors that explained its prevalence. This mode of infant feeding, therefore, is a traditional and widely practiced behavior, despite a large degree of acculturation and modernization in Nigeria within the last 20 years. This suggests that attempting to change mothers’ behavior in mode of feeding would be a difficult task indeed.

Problem definition: dietary intake and nutritional status of weanlings

To design an intervention to improve weaning patterns and nutritional status of infants and young children in Nigeria, it was essential to define the problem in quantitative terms:

A general description of dietary intakes and nutritional status of the target group of children is necessary to understand the consequences of infant feeding patterns, and to better define the program intervention strategy. It is difficult, if not impossible, to decide upon a program strategy without knowledge of &af (types and composition of foods) and how much children eat, and of the nutritional outcomes of these consumption patterns [S].

Three neighboring villages were selected for quantitative assessment of dietary intake of children aged 5-30 months, during diarrhea1 illness and health.

Surveillance of diarrhea1 morbidity was conducted to identify cases, which were then followed for two consecutive 12-hr days during diarrhea, two during convalescence, and two subsequent symptom-free days. Breastmilk consumption was estimated by test- weighing of the child, all other foods consumed were weighed, and intakes were converted to nutrients using food composition tables [ 1, 31. Samples of the ogi paste used to prepare pap were obtained to estimate water and protein content, while published values were used to estimate energy [ 1,3, 15-171.

Anthropometric measurements used to assess nutritional status for the sample of 45 children (Table 5) indicated considerable stunting and wasting relative to international standards [3]. These children were consuming an average of 738 kcal/day on symptom-free days, or about 60-70% of the recommended intake for children of similar age and reference body weight. The low intakes resulted primarily from the inadequate nutrient density of the pap, with a mean energy density of 26.2 kcal/lOOg (SD 16.8) and protein content of 0.44 g/100 g (SD 0.29). In order to meet the recommended energy intake, children would have had to consume at least 1.2 additional liters of this dilute pap, requiring an additional four meals per day (assuming a maximum gastric capacity of about 36Og, i.e. 45 g/kg body weight with a mean body weight of 8 kg) [18]. Given the ethnographic reports of mothers’ time constraints, it is unlikely that mothers could spare the additional time necessary for this increased number of meals. Likewise, our preliminary interviews suggested that the women would have resisted replacing the traditional pap with solid foods of greater energy density.

Infectious diseases also undoubtedly contributed to undernutrition of children in these communities. Field studies in many parts of the world, including other countries of West Africa [19-201, have found a negative relationship between the prevalence of diarrhea and selected febrile illnesses; and children’s rates of growth. However, these illness explain only a minor portion of the growth failure of children in LDC’s [Zl-221. Moreover, recent analyses indicate that the nutritional impact of infections can be eliminated by improvements in children’s usual dietary intake [23]. Thus, nutritional enhancement of the children’s general weaning diet in this setting seemed to be the most feasible approach to improve their nutritional status, either through fortifying the traditional pap or encouraging mothers to feed children a more ‘adult’ diet of solid food.

Intervention alternatives: earlier introduction of solidr or fortification of Ogi pap

Based upon data collected for the various phases of the DMD project, it became obvious that an

Table 5. Age, weight, length and relative nutritional status ofchildren at time of initial dietary study (n = 45)

Children Mean + SD Minimum Maximum

Age during observation (months) 13.2 _t 5.9 5.3 28.0 Weight (kg) 1.94 * I .70 4.54 12.91 Length (cm) 71.2 + 6.1 61.0 81.1 Weight for age Z-score -1.875 1.19 -4.62 0.80 Weight for length Z-score - 1.09 j: 0.84 -3.38 0.48 Length for age Z-score -1.63 + 1.19 -4.69 0.72

Weaning food in Kwara State, Nigeria 1107

intervention to improve weaning practices in Kwara State required the choice of one of the following two alternatives:

(1) mothers should be encouraged to feed a more diverse (“adult”) diet of semi-solid foods to children at an earlier age, or

(2) the traditional weaning food, eke, should be fortified with locally available and culturally acceptable ingredients to improve its nutritional quality.

Each of these alternative choices presented difficulties concerning necessary changes of behavior. Although we felt that the first option would probably have the greatest nutritional impact, its acceptance as an intervention strategy was perceived to be problematic. Convincing mothers to feed semi-solid or solid foods to children at an earlier age required that we overcome several strong cultural beliefs and patterns, including beliefs against feeding ‘adult’ or solid foods to children under one year of age and a clear preference for hand-feeding as opposed to spoon-feeding.

The second option of fortifying eke, however, was not considered to be an easy behavioral change to effect. Problems we hypothesized included the identification of appropriate supplemental ingredients that would improve the nutritional quality of the pap, lack of a ‘felt need’ by mothers to fortify what they already considered to be the ‘best’ food for their infants, the additional amount of time required by mothers to prepare and feed a fortified eko product, and the cost of the additional ingredients. Moreover, we were not certain that we could adequately fortify the traditional pap without changing it to a thicker consistency that would require a shift from handfeeding to spoon-feeding.

The choice between the two intervention alternatives required additional ethnographic data. We ex- panded the number of sites where unstructured interviews were conducted, and focused on a few specific research questions. In particular, we explored whether an earlier introduction of solids was possible, given the apparent cultural bias against offering them before the child was nearly one year of age. We also interviewed mothers and local ogi producers to probe whether fortifying the pap with additional ingredients would be acceptable.

Based upon the results of this ‘focused eth- nography’, we concluded that our best option was to promote a fortified eko. The additional ethnographic data confirmed our fears that mothers were adamant against feeding weanling age infants ‘adult’ foods and that messages promoting this behavior change would be unsuccessful. More- over, promotion of an earlier introduction ‘adult’ foods, which would be of thicker consistency than eko, would require that mothers switch from handfeeding to spoon-feeding-yet another behavioral change.

The decision to fortify the traditional pap required a series of small but related research projects, both to find the proper formulation of the product and to identify communication strategies that would lead to adoption of the new eko recipe.

Recipe triafs, product testing, and communications research

A list of possible ingredients for fortification was compiled, based on market surveys of available foods, prices, and cultural acceptability for feeding to infants and young children. Legumes such as cowpeas, chickpeas, and soybeans were the best plant protein sources to complement the cereal-based eko, and of these choices, cowpeas were much more widely available and most commonly consumed. Sugar and palm oil were identified as cheap energy sources, and palm oil would also satisfy the requirement for vitamin A.

A series of focus group interviews and ‘recipe trials’ in several villages introduced these possible food items to mothers and tested the acceptability of alternative weaning recipes in terms of taste, color, cost, consistency, and cultural perceptions. The methodology for the recipe trials adapted the procedures implemented for the Peru DMD project [6], which were drawn from techniques first developed in Indonesia for “The Weaning Project” [24-261. The conceptual basis of recipe trials derives from the principles of ‘new product management’, in which a product is developed in consultation with consumers [27-301. It is then tested, on a small scale, called (a ‘test market’), to determine the level of acceptability of the product and to detect any possible ‘flaws’ in the product and to identify optimal promotion and distribution strategies.

The strategy followed for Nigeria involved a series of focus group interviews with mothers from a number of villages [31]. Mothers were asked to suggest combinations of foods and new recipes of fortified eko that would be acceptable and appropriate for them to feed their own children.

Four new fortified eko recipes were developed and these were presented to small groups of mothers. Preparation of each recipe was demonstrated and a volunteer was asked to cook. Mothers tasted the fortified pap and fed it to their children, then ex- pressed preferences and made suggestions. The recipe trials demonstrated that the new recipe containing toasted cowpea, palm oil, and sugar was well- accepted by both mothers and children. Discussions focused on four sets of product-related questions: (1) was fortification of the traditional eko acceptable and which ingredients were most acceptable? (2) could mothers learn and would they teach the new recipe to others? (3) which characteristics of the new recipe were most and least acceptable? and (4) would they regularly prepare the new recipe and feed it to their infant?

The qualitative, exploratory nature of focus groups was ideal to examine reactions to a new product and behavior that deviated from traditional feeding practices, to identify possible factors of resistance, and to learn what messages might prove persuasive to the Nigerian mothers. This step of the research also showed that cooking demonstrations were a successful technique for transferring knowledge of the recipe and encouraging participation.

The development of a final, nutritionally balanced, fortified eko product was completed by a team of fieldworkers, trained in dietary methods, in order to

1108 MARGARET E. BENTLEY er al.

Table 6. DMD intervention recipe-Pap nutrient calculations

Ingredients Amount (g) Energy (kcal) Protein

Ogi paste 200 (I milk tin) 344 8.2 Cowpea flour 50 (4 tbsp) 171 11.6 Red palm oil I4 (2 tbsp) 123 0.0 Sugar 35 (2 tbsp) I40 0.0 Water 620 (2 bottles) - -

Malt flour 5 (1 tsp) - -

Energy density = 85 kcaI!lOOg wet weight. Protein density = 2.2 g/l00 g wet weight.

achieve the desired energy density ( > 80 kcal/ 100 g) (Table 6). Table 6 lists the ingredients and their amounts in the fortified eko recipe. Table 7 lists the steps of preparation.

The problem of obligatory spoon-feeding of the fortified eke was considered to be the most difficult issue. The final recipe was of a semi-solid consistency that prohibited hand-feeding of the eko, thus risking its rejection by the majority of mothers who normally feed in this way. Undertaking a broad educational campaign to change a traditional mode of feeding developed over generations seemed a formidable task. Fortunately, DMD investigators became aware of work by researchers in Tanzania and India [32-331 who had experimented with a processing technique to reduce the consistency, or viscosity, of weaning food. This technique uses sprouted grains to prepare a malt flour high in amylase, which will break down the starch of a thick gruel and produce a liquid consistency. The nutrient composition of the mixture, however, does not change when malt is added.

We learned that local sprouting of grains was commonly done in this part of Nigeria to prepare beer and other alcoholic beverages. Its use at the household level, however, was not common and grinding the sprouted grain to produce a malt flour was new. Also, the addition of malt to food was a new concept. A decision was taken, however, to include malt flour in the fortified eko recipe, as a way of eliminating the ‘mode of feeding’ problem.

Market research was undertaken to find a name for the new weaning food. Focus group interviews among mothers and health workers first established a list of potential names. Several of these were pretested among small groups of both urban and rural mothers. Based upon this work, the name Eko Ilera was chosen. In Yoruba, the word ilera means ‘health-giving’.

Further qualitative research to identify the best methods to promote Eko-Ifera was conducted during the ethnographic phases and during the recipe trials to identify the best communication strategy and messages. A major problem we perceived was the lack of a ‘felt need’ by mothers. The challenge was to find a way to motivate mothers to try the fortified pap, by appealing to a perceived benefit. As stated earlier, the traditional, dilute eko was considered to be an ideal

Table 8. Comparison of cost and kilocalorie value of traditional pap, Eko-Ilrro, and commercial infant cereal

Kobo’/lOO g Kcal,‘lOO g

Traditional pap 3 25 Eko -Ilera 5 85 Commercial infant cereal 20 85

*As of December, 1987 10 Kobo = I Naira; I Naira = $0.25.

infant food, a food that protects children from illness and from problems that are associated with the introduction of other foods. One area where we thought we might be able to appeal to mothers was to promote the new pap as a product that would lead to the production of a ‘healthy’ baby-one who is ‘light’ (fire) [35].

Issues of behauioral change

Although we were convinced, based on recipe trials and product testing, that we had a ‘good’ product (during behavioral trials, mothers and their infants accepted and liked the fortified eko, when it was provided to them), we were aware that we were asking for several changes in attitudes and behavior. These included:

(1) increased food preparation time; (2) an increase in cost of the infant food; (3) the preparation and use of a malt flour to produce

an acceptable consistency of product.

The first issue, preparation time, is of major con- cern. These Nigerian mothers work within the domestic, agricultural and/or market spheres, and they admitted that apart from the health-giving qualities of eko, one of its advantages was ease of preparation and short time required for feeding. With the traditional eko, mothers need only boil water to dilute the purchased (or home-prepared) ogi paste. Eko- Zlera, on the other hand, requires several food preparation and cooking steps. Included in this is the preparation of both cowpeas and malt. Cowpea, a common legume and available to most households, must be ground into flour. At present, malt flour is not available for purchase, but must be prepared by each household. In addition to the time issue, the use of malt in food is a new ‘technology’.

Cost of Eko-Ifera will be problematic for some families. When the new recipe was finalized, our estimates were that it would cost approximately 5 kobo/lOO g, compared to 2 kobo/lOOg for the traditional unfortified eko. Although twice as expens- ive, it compared very favorably to the popular tinned infant cereal, which cost more than 20 kobo/lOO g (Table 8). Subsequently, the economic situation in Nigeria has declined, and the price of all foodstuffs has risen, including the ogi paste that is used to prepare the traditional eko. Nevertheless, the price of Eko-Zlera remains much more favorable than the commercially produced weaning foods.

Table 7. Preparation of Eko Ilera

I. Pour 2 bottles of mineral water into a pot. Add two tablespoons of red palm oil. Bring to boil. 2. Mix until smooth 4 heaped tablespoons of bean flour in one milk tin of cold water. Add this to the pot mixing thoroughly to prevent

lumps. 3. Mix one milk tin of ogi with one milk tin of water. Stir until smooth. Add the ogi mixture to the pot. Cook properly. 4. Remove the pot from the fire. Add 2 heaped tablespoons of sugar. 5. Add I level tablespoon of malt flour. Stir until thin. 6. Put back on the fire and cook for 2 minutes.


Behavioral change, in this case adoption of the new recipe and sustained use, will depend on many factors. First, mothers and other caretakers must be convinced that this product is going to benefit their infants and young children in some way. In fact, if the fortified pap is used, there should be a visibIe improvement in child health and activity among very malnourished children, but an association between improved child health and feeding of the recipe may not be clear or convincing, especially for mild to moderately malnourished children. In addition, the nutritional benefits of Eko-Ilera could be offset if there is substitution of nutrients, e.g. if breastmilk intake decreases or if the fortified pap replaces nutrients from other foods in the usual diet [8]. Therefore, reinforcement of messages must occur through several channels, including face-to-face demonstration and follow-up, visual, and audio materials. Growth monitoring programs that incorporate the new weaning food would be an optimal way of motivating mothers and sustaining the intervention.

One reinforcement to mothers is the ready acceptance of the new food by children. Testing of the product after the recipe trials showed that children eagerly accepted the fortified pap, demonstrating to mothers its obvious palatability.

Pilot intervention

A pilot intervention was conducted in twelve villages by the state Ministry of Health. The main communication strategy was to teach the new recipe to mothers through use of face-to-face demonstrations. Each village health worker trained 20 ‘Teaching Mom’s’, who were each responsible for teaching 10 village mothers. Village cooking demonstrations were conducted, and traditional songs were composed by mothers that praised Eko-Ilera. These songs became an important part of the communications effort.

After the pilot intervention was completed, an evaluation was implemented, focusing on both nutritional and behavioral outcomes. The evaluation data has been presented separately and suggests that mothers’ concerns about increased preparation time and cost are important determinants of adoption and use of the recipe [8]. The information gathered during the evaluation will allow an adjustment of the intervention strategy and messages, if necessary, and an assessment of both major and minor constraints to adoption and sustained use. Issues of cost, mothers’ time, understanding and acceptance of messages, etc. should be carefully evaluated before the intervention is implemented broadly.

DISCUSSION

This paper has described factors that should be addressed in the design of an intervention to improve weaning practices. Numerous nutrition interventions worldwide have been attempted with varying degrees of success. Reasons for limited success of some projects may be that little attention was paid to sociocultural issues, while the focus was on improving dietary intakes without assessing the constraints at the household and community level. An exception are the excellent weaning interventions undertaken by the

Manoff Group, Inc. [24-261. These interventions pioneered the use of recipe trials, product concept testing, and social marketing principles for nutrition education programs in developing countries.

A key element in our approach has been to focus on both nutritional and sociocultural issues and to conduct a ‘dialogue’ with mothers and others regard- ing the type of intervention and recipe to be pro- moted. We believe a successful weaning intervention must define both the problem and the solution through the collection of information in both of these areas.

The use of ‘recipe trials’, we believe, holds great promise for the design of community based nutrition intervention programs [5-6, 24-26, 311. The project worked closely with Nigerian mothers in the early stages of developing the new recipe and also in the pretesting of the communication materials that were used by fieldworkers in explaining to mothers what the recipe consists of and what benefits mothers could derive from using the product. The development of a fortified pap recipe that was based upon mothers’ input about proper combinations of ingredients, taste, consistency, etc. allowed ‘ownership’ of the intervention by the target group and contributed to its acceptance by the community and the children.

One of our main objectives was to provide specific advice to mothers. This included a quantitative description of the new recipe-the ingredients and their amounts-and advice on how much to feed their child each day, depending on the age of the child. This was considered an essential component of our program communication strategy, as we were convinced that vague recommendations such as ‘feed your child more’ or ‘feed a balanced diet’ are neither nutritionally sound, nor do they motivate mothers to change their behavior [5].

Based on lessons learned from this project, we believe that nutrition education messages to mothers within less-developed countries should forego the traditional messages about “four food groups” or nutritional composition or adequacy. Rather, when introducing a new recipe or diet for young children, mothers need to be convinced about issues that are important to them. In this setting, those factors include ease of preparation, child acceptance of the food, and the relationship of the food to their child’s health, as culturally defined.

Despite the complexity of designing a weaning intervention that is nutritionally and culturally appropriate, we believe that it is possible to improve weaning practices and the nutritional status of infants in developing countries through nutrition education programs and following ‘rapid assessment procedures’ for problem definition and intervention design [l, 5-6,24-26,3 1, 34-351. Successful projects, however, will require an interdisciplinary approach, involving nutritionists, social scientists, and communications experts.

Acknowledgemenrs-This work was supported primarily by the Office of Nutrition, Agency for International Develop- ment, Cooperative Agreement No. DAN-1010-A-51 19-00, entitled ‘Dietary Management of Diarrhea (DMD) Project’. The authors gratefully acknowledge Molly Cogswell, Rebecca Stallings, Namvar Zoohori, and Joel Gittelsohn for

1110 MARGARETE. BENTLEY er al.

assistance in the analysis of some data presented in this study. Kitty Guptill is thanked for her review of the article and discussion of the evaluation results, Gretel Pelto, a pioneer in nutritional anthropology, was a member of the Directing Council of the DMD project. She provided much support and encouragement throughout the project. Earlier versions of this paper were presented at the following international meetings: (1) Workshop on Improving Infant Feeding Practices to Prevent Diarrhea or Reduce its Sever- ity: Research Issues. Sponsored by the World Health Organ- ization, Diarrhoeal Disease Control Programme and The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, MD, 25-28 April, 1988, and (2) Work- shop on Health Behavior and Child Survival: Individual, Household and Community Determinants, Case Western Reserve University, Cleveland, OH, 31 March-l April, 1989.

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Documents

Development of a nutritionally adequate and culturally appropriate weaning food in Kwara State, Nigeria: An interdisciplinary approach